Name: __________________________________

Date: _________________________________

 

Tick any of the words that describe your pain under the column that describes it's intensity

None Mild Moderate Severe
Throbbing
Shooting
Stabbing
Cramping
Gnawing
Burning
Aching
Heavy
Tender
Splitting
Tiring
Exhausting
Sickening
Fearful
Punishing/Cruel

Your Pain is:

On Most Days
No Pain
Mild
Moderate
Distressing
Horrible
Excruciating
At it's worst
At it's best
Today
 

*How many hours of the day are you in pain?
*How many days per week are you in pain?
*How many weeks per year are you in pain?
*What drugs have you taken today?
 

Please draw your pain:

XXX Burning = = = Numbness
!!! Stabbing *** Cramping
000 Aching ### Other

 
Your pain today (tick along the scale below)

No pain<-------------------------------------------------------------------->Worst Pain